|NASA Headquarters' Directives|
Effective Date: November 08, 2011
Expiration Date: June 08, 2019
Responsible Office: LM
|Mishap Reporting, Investigating, and Recordkeeping Program and Plan|
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7.1.1 The ex officio representative and HQ Safety Office investigator shall complete the SATERN "Introduction to Mishap Investigation" or an equivalent mishap investigation training course or NASA Root Cause Analysis Training, and be familiar with the investigation process described in HQPR. 8621.1, "Mishap and Close Call Reporting and Investigation Program", and NPR 8621.1, "NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Recordkeeping."
7.1.2 The HQ Safety Office IRIS administrator and other HQ Safety personnel shall be familiar with the investigation processes described in this NPR 8621.1B and this HQPR; IRIS; recordkeeping requirements of NASA Records Retention Schedule (NRRS); and the records handling requirements of the Privacy Act of 1974 as amended, 5 U.S.C. 552a.
7.1.3 The Human Factors Investigator shall, at a minimum, be knowledgeable of the methods to identify unsafe acts and errors, types of errors, causal and contributing factors of errors, performance-shaping factors, interview witnesses, analyze data, create timelines, fault tree analysis, barrier analysis, event and causal factor trees, to draw conclusions and generate recommendations to reduce human error or mitigate negative consequences of human actions; and basic knowledge of physical and psychological processes and limitations of humans.
7.1.4 The Investigating Authority (MIB, MIT, MI and ex- officio) shall have knowledge of the NASA incident investigation process, knowledge and skills to secure the site, preserve incident scene, interview witnesses, collect and impound data, records, equipment, facilities, create time lines, document facts, generate fault trees, perform barrier analysis, integrate evidence, draw conclusions, generate recommendations, and generate mishap reports.
7.1.5 For Type A, Type B, Type C, Type D, high- visibility and low-visibility incidents at least one member of the Investigation Authority (MIB, MIT, or MI) shall complete the "Introduction to Mishap Investigation training" course located on the System for Administration, Training, and Educational Resources for NASA (SATERN) or an equivalent mishap investigation training course prior to commencing the investigation, within the last one year.
7.1.6 It is highly recommended that all members of the Investigating Authority (MIB, MIT, or MI) complete Mishap Investigation training.
7.1.7 For Type A, Type B, and high-visibility incidents at least one member of the Investigation Authority (MIB, MIT, or MI) must have completed the instructor-led NASA Root Cause Analysis Training or an equivalent training course that addresses the events and conditions prior to an incident, identify cause and effect relationships, discriminate between barriers and controls, construct incident time line, and construct Event and Casual Factor Trees. The training must have been completed within the last three years.
7.1.8 It is highly recommended that all members of the Investigating Authority (MIB, MIT, or MI) complete the NASA Root Cause Analysis training.